tci Part B Insider - 2010 Issue 32

Reader Questions: CMS Spells Out MD's Role in E/M

Question: I've heard that for an E/M visit, the physician is responsible for certain parts of that visit. Does Medicare state this explicitly?Answer: In the E/M service documentation guidelines, CMS states that ancillary staff or even the patient (via questionnaire) may record the review of systems (ROS) and past, family, and/or social history (PFSH) portions of the history component.Be careful: To receive credit for these history elements, the doctor should date and sign the patient's chart to indicate he reviewed the entire history note.Straight from the source: The 1995 E/M guidelines state, "The ROS and/or PFSH...

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